The Appeal of Dermatology Residency

DECEMBER 16, 2019
Kevin Kunzmann
Douglas DiRuggiero, PA-C

Douglas DiRuggiero, PA-C

For some time now, dermatology has been a field in demand among aspiring physicians. But the benefits of reaching the field is partly due to a very limited rate of availability, and with patient populations increasing, there needs to be increased roles filled by specialists.

In an interview with MD Magazine®, Douglas DiRuggiero, PA-C, of The Derm Centers, explained what has constituted the current rate of dermatologists, and what role physician assistants and nurse practitioners have come to play as a result.

MD Mag: What does the current psoriasis care team look like?

DiRuggiero: Well certainly, we're going to have to go back to the beginning. We can't overlook the fact that patients with plaque psoriasis are presenting to all types of primary care clinics, and with their disease, often misdiagnose and often undertreat it by the time they make it into a dermatology clinic.

They have the potential of seeing a physician who's a board-certified dermatologist. We're seeing advanced practice clinicians are either a PA or nurse practitioner, all of whom can add a variety of experiences and comfort levels with treating psoriasis, and have a comfort level with the newer treatments that have come out

MD Mag: How do you think the team has evolved? Where do you think is it going? What will the care team look like in 5-10 years?

DiRuggiero: Well, I think it would be difficult to deny the fact that more and more nurse practitioners and PAs are entering, and already have a strong presence in the dermatology specialty. I think overall in the United States, we're seeing more and more that primary care in general is being taken over by NPs and PAs, and I think that we will see over the next decade, that physicians will gravitate more and more towards specialties—knowing that the basic primary care is going to be in comfortable hands of NPs and PAs.

Now, that doesn't mean we're not going to have multiple board-certified family and internal medicine, etc. But I think that the drive towards specialty medicine is going to become even greater in the decade to come. But even with that, we've seen such a shortage of dermatology care for an aging population of baby boomers and a Gen X population that's more concerned about their skin, with a long history of sun exposure, a lot of skin cancer, a lot of disease severity.

Historically, the AAD has kept the residency slots to such a low number, in order to make sure that specially wasn't oversaturated. I understand the logic behind that. But what's happening as the population has boomed well beyond what the residency could accommodate, it's left a large gap for nurse practitioners and PAs to fill. 

So, we're at a tipping point right now. Based on estimates, there's probably around between 4000-5000 PAs who practice full-time dermatology for board-certified dermatologists. And on the nurse practitioner side, it's somewhere between 3500-4000. I don't know their numbers exactly. But when you think about the fact that there's about 10,000 practicing dermatologists in the United States—ones that are doing office practice, there are a couple thousand more that are doing other things—our numbers are almost 1:1 right now.

And I suspect, whether people like it or not, we're probably going to have a ratio that's even more NPs and PAs to board-certified dermatologists over the next 5 years.

MD Mag: To your perspective, is there anything we need to change in education to help improve the current makeup and rate of rheumatology personnel?

DiRuggiero: Right now, one of the most difficult residencies to get into is dermatology. Historically it was the three Os, is what you always heard: ophthalmology, orthopedics, and otolaryngology were the 3 most difficult residences to get. But over the last 15-20 years, dermatology has risen to become the most competitive. It's got the smallest number of slots, and it produces a good lifestyle. People will see that and are attracted to it.

And it's also just extraordinarily interesting, as procedural medicine combined with general medicine care. You see kids, you see old patients. So it kind of hits all those buttons.

And all of that has made it especially highly sought after, which means that over the last 20 years, you have to be literally top of your class to get into a dermatology residency. I mean, if you're not top 5% and have everything else, you won't even have a chance of getting in.

Dermatologists have always been extraordinarily bright and are always upper-tier. But in the last couple decades, it has produced a population of board-certified dermatologists in the United States that are just really the top of the top. And you can see that when you go to conferences and you hear people lecture—they are really extraordinary.

Now, not all of them coming into our residency are choosing to go into medical care there. There's a lot of big pull towards surgery, towards cosmetics. So keeping those extraordinarily bright, accomplished folks in medical dermatology is something that their academy is going to have to address, and keep them strongly interested in caring for the whole patient and taking on diseases that can take a lot of time in the office. 

A lot of that time with patients is being relegated to the PA, to the nurse practitioner, because our training models is towards that—towards holistic patient care, taking more time with folks. I think that I don't want to be ever viewed as being in competition with our supervising physicians, but being viewed as a compliment to them, so that we can offer that to their patient base and being an extension of them.

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